1. "Smoking" electronic cigarettes: A reasonable harm-reduction and smoking- cessation strategy? Seth Bilazarian MD Private practice blog on theheart.org Private practice blog theheart.org

2. E-cigarettes – What are they? (1) Are they a reasonable harm-reduction strategy? (2) Are they a reasonable smoking-cessation strategy?

3. "Doc, I'm using the electronic cigarette"

4. What is being asked? Is the e-cigarette healthy? no (see next question) Is it healthy to use a nicotine drug-delivery system in which a heated vapor of propylene-glycol– or glycerin-based liquid is inhaled into the lungs for drug absorption through the alveolar membrane for recreational enjoyment? no Is the e-cigarette a reasonable strategy for short-term use as a transition from smoking to cessation? unknown Is the e-cigarette a reasonable harm-reduction strategy compared with tobacco smoking? probably

5. What is an electronic cigarette? Designed by Chinese pharmacist Hon Lik in 2003 Electronic device that simulates the act of smoking a real tobacco cigarette by producing an inhaled vapor offering the "freedom to smoke anywhere" Gives the appearance, physical sensation, and even flavor of a real cigarette

6. How does it work? User inhales on the mouthpiece, triggering the liquid to be heated, and the atomizer turns the liquid into a vapor The vapor is inhaled by the user, which gives the effect of smoking a real cigarette Users are "vaping," not smoking

7. Alleged benefits of e-cigarettes No tar, tobacco, carbon monoxide, or ash It is possible to get the same amount of nicotine as a regular cigarette Each cartridge costs less than $2 and is equivalent to an entire pack of cigarettes (possible savings of over $1000 a year) Don't get the same "smoke" smell because there's no smoke (and also no secondhand smoke) Delivers nicotine effectively and more rapidly Significantly reduces cigarette craving and number of cigarettes smoked at a level similar to that of nicotine- replacement products

8. What's the attraction? Price difference: Price of cigarettes are past $5.00, and a major factor in peoples' choice to switch to change to e-cig is that economical advantage. The cartridge to refill an e-cig is roughly $3.00 apiece and can last three to five times as long as a traditional pack of cigarettes. Many estimates say an e-cigarette habit costs one-third as much as a smoking habit. One benefit is also that you are in charge of how much you smoke. You don't have to smoke the entire cigarette in one sitting, you can take one or two puffs and be done. What do people see in them? No burning tobacco No CO 2 in your lungs, no secondhand smoke Adjust the amount of nicotine More economical (user can take as many "hits" as desired and need not smoke the entire thing in one sitting) Attraction to youth: The economic reason above appeals to high-schoolers Attractive for youth to smoke however much they want Students MAY feel there is a lower risk of addiction No smoke smell and feeling in lungs Easy to buy online or in a mall and come in flavors ranging from chocolate to bubble gum; you can buy them in pink, gold, or blue Presumption of safety because it is not burning tobacco, even though its consequences are not known

9. The negative aspects of e-cigarettes After the FDA analyzed brands it found diethylene glycol and other cancer-causing agents in some samples The nicotine cartridges emit an inconsistent amount of nicotine > for example: if you are using a low-strength nicotine cartridge you may actually receive the same amount as a higher dose Like secondhand smoke, particles from the vapor can land on surfaces like clothing, furniture, and carpets and have the same affect as secondhand smoke The FDA remains concerned about how e-cigs are marketed and about how they are encouraging youth tobacco use as well Essentially no data on use as cessation strategy (J Med Case Rep 2011; 5:585) n=3 Harm-reduction data limited (BMC Public Health 2011; 11:786) n=40

10. Conclusion May be harmful to public health. Smokers have been advised by the FDA not to use them. They promote increased airway resistance after five minutes of use http://chestjournal.chestpubs.org/content/141/6/1400.abstract?sid= 790ab787-0292-4deb-b172-cbf3861469b3 http://chestjournal.chestpubs.org/content/141/6/1400.abstract?sid= 790ab787-0292-4deb-b172-cbf3861469b3 More research is needed on the cost/benefit equation of these products and the appropriate level and type of regulation for them. The harms have tended thus far to be overstated relative to the potential benefits. Concern over repeated inhalation of propylene glycol. Concern that e-cigarettes may promote continued smoking by allowing smokers to cope with no-smoking environments is countered by the observation that most smokers use these products to try to quit and their use appears to enhance quitting motivation. Concerns over low nicotine delivery are countered by evidence that the products provide significant craving reduction despite this in some cases; and e-cigarettes may help reduce toxin exposure to nonsmokers. E-cigarettes are a new trend on high school campuses.

11. What I tell patients about e-cigarettes Definitely not healthy Might be safer than smoking If patients are interested in quitting smoking, they should be strongly directed toward evidence-based treatments such as counseling and nicotine replacements like a patch or gum, rather than to e- cigarettes Might work as a strategy to quit smoking similar to nicotine replacement–most like Nicotrol inhaler If you try it, commit to short-term use It may be called an e-cigarette but it's still a cigarette

12. References E-cigarettes: Promise or peril. Nurs Clin N Am 2012; 47:159-171. Wagener TL, Siegel M, Borrelli B. Electronic cigarettes: achieving a balanced perspective. Addiction 2012. DOI: 10.1111/j.1360- 0443.2012.03826.x. Abstract.Abstract

13. Opinions from other doctors on the internet (not my opinion) "The greatest issue with cigarettes is the 500+ other ingredients added, not just the nicotine. Do we recommend this for nonsmokers? Of course not, but for current smokers this is the most revolutionary device to date." –Dr. Travis Stork from "The Doctors" (thesmartsyleliving.com) "E-cigs are an attractive option when coupled with a message of being less harmful, particularly as the cost of cigarettes and smoke-free environments continues to increase....If these devices can be shown to help more people quit completely, this would represent a true reduction of harm for users and the population as a whole. However, no scientific basis currently exists for making claims of either reduced harm or safety for e- cigs. Furthermore, e-cig use has potential unintended consequences, such as youth appeal, leading to increased smoking initiation, or dual use of different tobacco products by a single user, derailing the potential for ultimate smoking abstinence." (E-cigarettes: Promise or peril? Riker, Darville, Lee, Hahn)